Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • Suspected myxoedema coma, for example:
    • severe primary hypothyroidism
      • thyroid stimulating hormone (TSH) greater than 100mU/L
    • altered conscious state
    • hypothermia temp less than 355c
    • hyponatraemia less than 125mmol/l
    • congestive heart failure or major fluid overload
    • possibility of secondary hypothyroidism
    • bradycardia less than 50 beats/min
  • stridor associated with a thyroid mass
  • possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network 

Southern Adelaide Local Health Network


  • clinically stable hypothyroidism
  • primary hypothyroidism (except in patients with cardiac disease, pregnancy or if thyroxine treatment is contraindicated) that has not been treated with replacement therapy
  • uncomplicated hypothyroidism and subclinical hypothyroidism, except in pregnancy or pre-pregnancy
  • unexplained fatigue without endocrine disorder

Triage categories

Category 1 - appointment clinically indicated within 30 days

  • pregnant and postpartum thyroiditis
  • severe hypothyroidism (TSH greater than 100mU/L)
  • suspected or confirmed secondary hypothyroidism
    • low thyroxine (T4) without a raised thyroid stimulating hormone (TSH)

Category 2 — appointment clinically indicated within 90 days

  • hypothyroidism with difficulty normalising thyroid function tests (TFTs) despite thyroxine therapy
  • hypothyroidism within 12 months of delivery of a child
  • pre-pregnancy counselling

Category 3 — appointment clinically indicated within 365 days

  • problems with management of primary or secondary hypothyroidism
  • euthyroid goitre without airway compromise

For information on referral forms and how to import them, please view general referral information.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • identifies as Aboriginal and/or Torres Strait Islander
  • relevant social history, including identifying if you feel your patient is from a vulnerable population and/or requires a third party to receive correspondence on their behalf
  • interpreter requirements
  • past medical/surgical/reproductive history
  • pregnancy – established or planned
  • family history
  • allergies and sensitivities
  • use/frequency of alcohol, tobacco, and other drugs
  • current medications and dosages, including supplements
  • onset, duration, and progression of symptoms
  • management history including treatments trialled/implemented prior to referral
  • physical examination
  • height/weight
  • body mass index (BMI)


Thyroid function tests (TFTs):

  • thyroid stimulating hormone (TSH)
  • free thyroxine (FT4)
  • free triiodothyronine (FT3)
  • thyroid peroxidase (TPO) autoantibodies if primary hypothyroidism

Clinical management advice

Primary hypothyroidism, stemming from thyroid dysfunction, is generally manageable within a general practice setting unless specific concerns emerge:

  • consider the potential coexistence of other autoimmune glandular disorders in instances of autoimmune hypothyroidism, such as pernicious anaemia, celiac disease, and Addison's disease
  • always confirm hypothyroidism by repeating the thyroid-stimulating hormone (TSH) test before initiating treatment
  • if cardiac symptoms present, commence low dose of thyroxine and gradually adjust the dosage over several months
  • suspected hypothyroidism but TSH levels remain normal, explore the possibility of secondary hypothyroidism originating from pituitary or hypothalamic dysfunction.

Secondary hypothyroidism is rare and typically occurs alongside deficiencies in other pituitary hormones. Evaluation of secondary hypothyroidism should involve consultation with an endocrinologist. When appropriate, administer cortisol replacement before initiating thyroxine treatment. TSH levels are inadequate for guiding thyroxine replacement in patients with pituitary dysfunction.

The objective is to maintain thyroxine (T4) levels within the upper mid-range of normal. Refrain from commencing T4 therapy for secondary hypothyroidism without consulting an endocrine specialist.

Please ensure that recent pathology results are available. Consider providing the patient with a repeat pathology form at the time of referral.

Patients who have previously received care from a specialist should be encouraged to return to their care for additional assessment if needed.

Referrals are subject to the evaluation of the triaging clinician. If you believe your patient necessitates specialist assessment but may not meet the provided criteria, feel free to connect with the specialist team to discuss your concerns.

Suggested General Practitioner management

  • confirmed or planning pregnancy maintain TSH levels below 2.5 mU/L
  • suspected or confirmed secondary hypothyroidism - refer the patient urgently
    • do not initiate thyroxine treatment until hypocortisolaemia is excluded
  • slightly increased TSH levels (below 7.5 mU/L) may be noticeable in individuals with an elevated body mass index (BMI)
  • if thyroid peroxidase (TPO) antibodies are not present, replacement therapy may not be necessary.

Clinical resources

Consumer resources